A nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

A) The presence of cerumen in the ear canal:
This is incorrect. The presence of cerumen (earwax) in the ear canal is not inherently abnormal. In fact, cerumen is a natural substance produced by the body to protect and clean the ear canal. While excessive buildup can lead to blockages or hearing impairment, some amount of cerumen is normal and does not indicate an abnormal finding.

B) A shiny, pearly white color tympanic membrane:
This is incorrect. A shiny, pearly white tympanic membrane is a normal finding. This color and appearance indicate a healthy, intact eardrum. The tympanic membrane should be translucent with a smooth surface and this typical pearly appearance in a healthy ear.

C) A clear presence of a cone of light:
This is incorrect. The cone of light is a normal finding during otoscopic examination. It is a reflection of the otoscope light off the tympanic membrane and should be visible in the anterior-inferior quadrant of the tympanic membrane. The presence of the cone of light suggests that the eardrum is intact and in a normal position.

D) A yellow or amber color to the tympanic membrane:
This is the correct answer. A yellow or amber color of the tympanic membrane suggests the presence of fluid behind the eardrum, which may indicate an ear infection or otitis media. This color change is considered abnormal and should prompt further investigation, as it can be a sign of inflammation, infection, or the accumulation of fluid in the middle ear.

A) Crackles: Crackles are abnormal lung sounds often associated with conditions such as pneumonia, heart failure, or pulmonary edema. They result from fluid in the airways or alveoli. However, crackles are not typically the primary finding in pleuritis, which involves inflammation of the pleura.

B) Stridor: Stridor is a high-pitched wheezing sound caused by an obstruction or narrowing of the upper airway, often seen in conditions such as croup or anaphylaxis. It is not characteristic of pleuritis, which involves inflammation of the pleura and not airway obstruction.

C) Dyspnea: Dyspnea, or difficulty breathing, is a common symptom in many respiratory conditions, including pleuritis. While pleuritis can lead to discomfort during breathing, dyspnea itself is not a sound that would be auscultated. It’s a subjective feeling that would be noted during the client’s history or verbal report, rather than an auscultatory finding.

D) Friction rub: A pleural friction rub is the most expected finding when auscultating a client with pleuritis. This sound occurs when the inflamed pleural layers rub against each other during breathing, producing a grating, scratchy sound. The nurse will typically hear this sound best on inspiration or expiration and it is the hallmark sign of pleuritis. The presence of a friction rub indicates the pleural inflammation characteristic of this condition.